<include file="header" />
<body class="bind-bg">
<div class="wraper" js="wapjs/nskj/js/install">

    <div class="bind-form">

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-person text-blue"></span></div>
            <div class="form-input pull-left"><input id="name" placeholder="请输入您的姓名"/></div>
        </div>

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-phone text-blue"></span></div>
            <div class="form-input pull-left"><input id="mobile" placeholder="请输入您的手机号码"/></div>
        </div>

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-phone text-blue"></span></div>
            <div class="form-input pull-left">请输入您所在地区:<input id="province" placeholder=""/>省<input id="city" placeholder=""/>市<input id="area" placeholder=""/>区</div>
        </div>

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-phone text-blue"></span></div>
            <div class="form-input pull-left"><input id="address" placeholder="请输入您的详细地址"/></div>
        </div>

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-xuexiao text-blue"></span></div>
            <div class="form-input pull-left">
                <select id="type">
                    <option value="0">请选择服务类型</option>
                    <option value="1">上门安装</option>
                    <option value="2">上门维护</option>
                    <option value="3">上门维修</option>
                    <option value="4">用户送修</option>
                </select>
            </div>
        </div>

        <div class="form-list clearfix">
            <div class="form-icon pull-left"><span class="iconfont icon-phone text-blue"></span></div>
            <div class="form-input pull-left"><textarea id="memo" placeholder="请输入备注信息(选填)"></textarea></div>
        </div>

        <a href="#" class="btn bg-blue text-center confirm">确定</a>
        <a href="/index.php?g=nskj&m=nskj&a=userCenter&machineId={BEESCRM:$machineId}" class="btn bg-orange text-center">取消</a>
    </div>
</div>
<script>

</script>
<include file = "footer"/>